Delegation

NCLEX Question
A nurse working in a busy long-term care facility needs to delegate to the
unlicensed assistive personnel she is working with. Which of the following tasks
would be appropriate to delegate? Select all that apply.

A. Performing an initial assessment

B. Checking vital signs
C. Setting up oxygen
D. Listen to the client’s lung sounds
E. Administering acetaminophen for pain score of 3
Answer: B and C
A is incorrect. Performing an initial assessment is not an appropriate task to delegate.
Assessment is out of the scope of practice of unlicensed assistive personnel.

B is correct. Checking vital signs is an appropriate task to delegate.

C is correct. Setting up oxygen is part of routine room set up and is an appropriate

task to delegate.

D is incorrect. Listening to the client’s lung sounds requires assessment, which is out
of the scope of practice of unlicensed assistive personnel.

E is incorrect. Administering medications is out of the scope of the unlicensed

assistive personnel
 NCLEX Question
A registered nurse and a licensed practical nurse are working together in a
psychiatric ward. Which of the following clients may the RN assign to the LPN?

A. A client taking amitriptyline, now swinging his jaw and grimacing.

B. A client with dementia that is confused and disoriented.
C. A client with bipolar disorder and a Lithium level of 2.0 mEq/L.
D. A client with a history of chronic alcoholism experiencing delirium tremens.

Answer: B
Choice B is correct. Clients with advanced dementia are expected to be confused and disoriented. In the
absence of any new or acute int the mental status, the LPN is fully qualified to take care of this client.

Choice A is incorrect. Client receiving amitriptyline, swinging his jaw, and grimacing is showing signs of acute
dystonia, a potentially serious condition arising from taking antipsychotic medications. Acute dystonic reactions
must be treated right away. This patient should be handled by a qualified psychiatric nurse.

Choice C is incorrect. A client with a Lithium level of 2.0 mEq/L is having severe Lithium toxicity. This client
should be taken care of by a registered nurse. A safe blood level for Lithium level is 0.6 mEq/L to 1.2 mEq/L. A
level of 1.5 mEq/L or greater is considered toxic. Severe toxicity may occur at a level greater than 2.0 mEq/L,
which can be life threatening.

Choice D is incorrect. Delirium tremens is a sign of severe alcohol withdrawal. It is associated with rapid onset
of confusion and sometimes, characterized by hyperthermia and seizures. Such patients demonstrate
unpredictable and unstable outcomes. Handling patients with Delirium Tremens needs frequent assessments
and critical thinking. Such patients should not be assigned to an LPN.
 NCLEX Question
The nurse and the LPN are working a busy shift at the pediatric ward. The nurse,
to provide efficiency in the ward, should delegate which task to the LPN?

A. Administration of a medication in syrup form to an infant with a cleft palate

B. Providing discharge instructions to the mother of a child with epiglottitis
C. Changing of a colostomy bag to a toddler with anal atresia
D. Assess a child’s developmental level

Answer: C
Choice C is correct. The LPN can perform a colostomy change. This is a routine nursing procedure that the LPN can
perform adequately.

An LPN (Licensed practical nurse) scope of practice includes providing ostomy care, monitoring the findings of
Registered Nurse, reinforcing patients education, administration of most medications in stable patients, caring for
ostomy sites/tubes; enteral feeding and checking for feeding tube patency.

An LPN may not perform initial assessment: Initial assessments are to be performed by a registered nurse (RN). The
first assessment is to be used to determine a patient’s baseline and develop an initial nursing plan of care. Once the first
assessment has been completed, and the nursing plan of attention has been developed, the LPN may assist the RN in
nursing process. The LPN is to communicate any change of a patient’s status to the RN.

Choice A is incorrect. The LPN cannot administer medications in this case of a child with a cleft palate. This is because
a child’s cleft palate poses a risk for aspiration to the infant. This needs the expertise and assessments of the registered
nurse.

Choice B is incorrect. The LPN cannot provide discharge instructions.

Choice D is incorrect. Assessment of a child’s developmental level needs the skills and expertise of the nurse.
From the Board of Nursing….

“The licensed nurse cannot delegate

nursing judgement or any activity that
will involve nursing judgement or critical
decision making”
 NCLEX Question
Due to an absent staff nurse, the postpartum unit is assigned a nurse from the
medical ward as a floater. Which of the following clients should the charge nurse
assign to the float nurse?

A. A 20-hour postpartum client who will be discharged the following morning

B. A 16-hour postpartum client who had eclampsia during delivery
C. A 10-hour postpartum client who has soaked 4 perineal pads in one hour.
D. A 5-hour postpartum client whose fundus is still not at the miline.

Correct answer is B. This client can be assigned to the float nurse. The nurse is floating from the medical unit to the postpartum
unit. Eclampsia is a complication of preeclampsia and is characterized by high blood pressure and seizures. This client remains at
risk for a seizure. The goals of management of Eclampsia involve controlling seizures and controlling hypertension. Medical unit
nurses understand and are experienced in taking care of clients having seizure.

Choice A is incorrect. The client is being discharged from the postpartum unit. She needs to be assessed whether she has the
capability to take care of her baby once at home. She also needs to be educated by the nurse about newborn care. A specialized
nurse with postpartum unit-specific experience should be assigned to this client.

Choice C is incorrect. This clients seems to be having primary Postpartum Hemorrhage (PPH). Uterine atony is one of the leading
causes of PPH. Specialized interventions (uterine massage, starting Pitocin drip, etc.) may be needed to control PPH. Therefore, a
dedicated nurse with postpartum unit-specific experience should be assigned to this client.

Choice D is incorrect. Soon after delivery, the uttering fundus (upper portion of the uterus), is midline and at 1 to 2 hours
postpartum, it is palpable halfway between the symphysis pubis and the umbilicus. About 12 hours postpartum, the fundus is at
level of the umbilicus. In this scenario, at 5 hours postpartum, the client’s fundus is not yet at the midline. This means the fundus is
displaced, and the most frequent cause of a displaced fundus is a full bladder. A full bladder may predispose to postpartum
hemorrhage because it interferes with normal involution (contraction) of the uterus. The client should be asked to void. The
medical nurse is usually not specialized in palpating the fundus, and therefore, this client should be assigned to unit-specific
experienced nurse.